Organization
SOUTHERN OREGON NEUROPSYCHOLOGICAL CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL R VILLANUEVA PSYD (OWNER)
(541) 608-3878
Entity
Organization
Contact information
Practice address
837 ALDER CREEK DR, MEDFORD, OR 97504
(541) 608-3878
(541) 608-3880
Mailing address
837 ALDER CREEK DR, MEDFORD, OR 97504-8911
(541) 608-3878
(541) 608-3880
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
—
—
103TC0700X
Clinical Psychologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
042601
—
OR
Enumeration date
12/14/2006
Last updated
07/16/2018
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